Alabama Medicaid's Form 342 is the one-page request for prior review and authorization of non-pharmacy services, from surgery and DME to home health, therapy, transportation and private duty nursing. The requesting provider codes the service type, diagnoses and prognosis, lists each service line with dates, place of service, procedure code, modifier and units, adds a clinical statement and signs a certification of medical necessity.
The requesting provider, such as a physician, DME supplier, home health agency or therapist, completes the form and signs; a rendering provider block identifies who will deliver the service. The signer certifies that the form and any attached letterhead statement were completed by them or their employee and reviewed by them.
Download the current version from the source each time; forms change without notice.
Prior Review and Authorization Request
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The service type codes on the form include medical care, surgery, DME purchase and rental, home health, physical, occupational and speech therapy, dental care, oral surgery, maternity, inhalation therapy, prosthetic devices, vision, psychiatric care, case management, LTC waiver, medically related transportation and private duty nursing.
That the requested service, equipment or supply is medically indicated, reasonable and necessary for the patient, that a physician-signed order is on file if applicable, and that the information is true, accurate and complete. The form warns that falsification, omission or concealment may bring civil or criminal liability.
Yes. Requests can go through the Alabama Medicaid Interactive Web Portal as well as on paper to Gainwell. Radiology studies, such as CT, MRI and PET scans, and cardiology services must be requested through the web portal rather than on paper. The current fillable form is revised 03/2023.